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Dr. McCammon is voluntary associate clinical professor of neurology at the University of California-San Diego.

Richard Powers' latest novel, The Echo Maker, which won the 2006 National Book Award for Fiction, is a busman's holiday for neurologists. It is both a detailed and affecting story of the aftermath of traumatic brain injury and a novel of ideas exploring multiple aspects of memory, how the brain decides what perceptions are true, and the nature of the self.

A MYSTERIOUS ACCIDENT

The story begins in Kearney, NE, near a refuge for migrating sandhill cranes (the “echo makers” of the title). One night in February 2002, young Mark Schluter drives off a straight, deserted road and flips his truck. Alcohol and drugs are not involved, and he is known as an excellent driver. The police receive an anonymous call from a gas station, but no witnesses come forward. A mysterious note appears at his bedside: “I am No One/but Tonight on North Line Road / GOD led me to you/ so You could Live / and bring back someone else.”

After a brief lucid interval, Mark's intracranial pressure rises and he is comatose for two weeks. The portrayal of his gradual, jumbled return to awareness is harrowing and quite believable. Eventually, he starts to speak but is disinhibited and emotionally labile. Worst of all, he develops Capgras syndrome. He is convinced that Karin, his sister and only living relative, is an imposter. His beloved dog, his house, and most people, also seem to be very clever copies. Mark's struggle to understand why some unknown agency has created this “Android Invasion” becomes increasingly convoluted and paranoid.

Mark and Karin's dysfunctional upbringing is gradually revealed. Mark, though intelligent, has never quite fit in. At age 27, he remains an aimless underachiever, usually amiable but at worst aggressive and difficult to deal with. As Karin describes him, he has both relied on her to get him out of jams and abused her emotionally, preying on her vulnerabilities as only a sibling could. Mark's insistence that she is not his sister, and his idealization of the “real Karin,” take an enormous toll on her as she realizes that his recovery is not the new beginning she hoped for. Rather, Mark will be her responsibility forever, condemning her to life in the town she has spent years trying to escape.

Although the medical team achieved a great save and the local neurologist has done all he can, Mark clearly cannot work or return home alone. Karin learns of Gerald Weber, a cognitive neurologist who has written a series of popular books, case studies of unusual neurological symptoms and perceptual anomalies, and writes to him. Intrigued, Weber examines Mark but does not stay long. He is remote from clinical practice and has little to offer for treatment. Karin feels, as many desperate family members do, that Weber isn't listening and is using Mark for his own ends.

WEBER'S DOWNWARD SPIRAL

Weber, whose books are reminiscent of Oliver Sacks and other medical writers, is famous and successful, yet he is unaccountably affected by a bad review of his latest book. The review is followed by articles that question his work as too anecdotal or philosophical, implying that medical case histories are intrusive and violate professional ethics. Weber can be scathing about fashions in scientific theory, but he harbors anxieties that he is falling behind in his own research and losing his edge. He begins to crash and burn during a foreign book tour, when he gives an interview while severely jet-lagged. His lectures become incoherent and his teaching deteriorates.

Yet he is ever the scientist, and even as he suffers there is a joke that neurologists especially will enjoy. At a reception, famished after a long day at a conference, Weber has a flash that “The entire room developed Kluver-Bucy: popping things in their mouths like babies, carrying on a little too manically…propositioning anything that moved.” Social gatherings may never seem the same.

LAYERS OF MEANING

Clearly, Powers has much more than a peculiar neurological syndrome in mind. Capgras is elevated to a metaphor for society's inability to distinguish the real from the fake. As portrayed in the novel, America — from the post- 9/11 period to the start of the Iraq war in 2003 — seems disconnected from itself. The world has “gone strange,” but world events still scarcely impinge on peoples' everyday lives, even when the local National Guard is mobilized to go to Iraq. Many paranoid theories, no less bizarre than Mark's, float through the collective national consciousness.

The characters embody the vertiginous idea that the self is both mutable and a construct of the brain. Mark exemplifies the self whose internal validation systems are damaged so that he doubts everything but himself. By contrast, for Karin and Weber their sense of self gradually collapses under the onslaught of external doubt and criticism hostile to their deepest sense of who they are. They begin to feel that they must be imposters.

The cranes seem to represent primordial, instinctual nature, in contrast to humans, who appear to be dooming the cranes and countless other species, including themselves, to extinction. A subplot about environmentalists struggling to prevent development of the crane's sanctuary underscores this point.

COGNITIVE NEUROSCIENCE

Richard Powers is known for his erudition and breadth of interests, and he has really done his homework. (As an aside, he is also a MacArthur Fellow and recipient of the Lannan Literary Award and James Fenimore Cooper Prize for historical fiction.) Long and intrusive as they may be, Powers' descriptions of current research into neural circuits, mirror neurons, disconnection syndromes, and how the self is formed and maintained are fascinating and possibly new to many not involved in basic science.

However, the encyclopedic list of syndromes began to seem oppressive rather than central to the story, and I suspect will leave much of the general public glassy-eyed. In addition, Powers strains credulity by piling additional delusional misidentification syndromes on poor Mark.

MEMORABLE CHARACTERS

Although some of Powers' previous books have been described as emotionally chilly and overly cerebral, memorable characters are one of The Echo Maker's greatest pleasures. Besides Mark and Karin, the other characters, such as Mark's redneck buddies, his girlfriend who works at a historical theme park, the saintly aide who is the only person Mark really trusts, the ascetic environmentalist, and the local developer, all come to life here. Though their flaws sometimes come close to parody, they are all complex individuals who can be likeable, infuriating, funny, crude, inscrutable, and heartbreaking. One wants to step right into the story to plead with them or try to set them straight.

About midway through, the book became repetitious and my attention began to wander. I couldn't take seriously the notion that neurological case studies, which have a long and illustrious history, are dishonorable or outmoded.

Just in the nick of time the story regained momentum, and the mysteries about the cause of the wreck, the identity of the caller, and the origin of the note are neatly resolved. The fates of the main characters, however, are more ambiguous.

This was my introduction to Richard Powers, who has a large and devoted following. Though not a perfect book, The Echo Maker is gripping and thought-provoking, with a story that is uniquely relevant to neurologists. While it requires some time and attention, it is a book to be savored and pondered.

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